The Kingdom of the Netherlands is made up of the Netherlands (its territory in mainland Europe), three autonomous constituent countries (Aruba, Curaçao and Sint Maarten), and three special municipalities (Bonaire, Saba and Sint Eustatius) located in the Caribbean. Both in its European and overseas territories, care in prisons is administered by the Ministry of Justice.

Around 60% of prisoners present with at least one mental disorder. Prisoners suffering from severe disorders have to be placed in Extra Care Facilities (Extra Zorgvoorziening, EZV) present in each prison.
People declared not criminally responsible can be subjected to a treatment order if the offence they committed results in a sentence of at least four years in prison. Those falling under that order are “made available” (Terbeschikkingstelling, TBS) for psychiatric treatment. They are transferred by a TBS court order to one of two types of specific psychiatric facilities: either the Forensic Psychiatric Centres (Forensisch Psychiatrisch Centrum, FPC), or the Forensic Psychiatric Clinics (Forensisch Psychiatrische Klinieken, FPK). The TBS can either be “conditional” (certain conditions are subject to consent) or “unconditional” (all conditions are obligatory). Those deemed to have diminished criminal responsibility can be sentenced to both prison and a TBS. In this case, they would serve their sentence before being placed in a specific Penitentiary Psychiatric Centre (Penitentiair Psychiatrisch Centrum, PPC). Prisoners in need of psychiatric care can also be placed in these facilities.
There are no specific facilities for people held under a TBS in the nation’s Caribbean territories. Therefore, they are either transferred to the Netherlands or remain in prison. In 2016, a man sentenced to life in prison received no mental health care in Aruba and Curaçao despite the expert psychiatric assessment recommending he be placed in treatment. A complaint was filed that same year with the European Court of Human Rights (ECHR) which held that the country had violated Article 3 (prohibition of inhuman or degrading treatment).

The TBS aims to offer each patient care that meets the needs posed by their mental disorder and facilitate their reintegration into society. Preventing repeat offences has, however, for several years now, seen a shift from a care-based to a security-oriented approach. Ensuring the patient’s reintegration into society has become secondary.

Around 60% of prisoners suffer from a mental disorder. People placed in care under a TBS order represent a significant proportion of that number. In ordinary prisons, mentally ill prisoners placed in isolation for medical reasons are held in disciplinary isolation cells. The CPT highlighted how this posed a risk of confusing these prisoners about the reason for their isolation.

Each prison has an EZV. The detention regime in the EZV units is similar to that in the rest of the prison. Prisoners with severe mental illness should, in theory, be placed in these facilities, and transfer requests come from either the medical staff or the prisoners themselves. However, whether or not it is approved is at the discretion of the prison director. The decision can be influenced by the type of crime committed. If approved, a prisoner stays in the EZV for a lengthy period of time during which they are assigned a supervisor from the prison staff. The CPT pointed out that an additional effort had been made to decorate the facilities and offer activities to the prisoners. The CPT delegation “gained a very good impression” from the EZVs, and suggested that they could serve as a model to other countries.

The Curaçao Centre for Correction and Detention has a forensic psychiatric support unit (FOBA), which accommodates prisoners in need of psychiatric care following a decision from the prison’s psychiatrist. Untried prisoners can also be placed there for the purpose of psychiatric observation. Prisoners residing in these units are offered activities (sport, music and ICT lessons), as well as four hours outside every day for exercise. In Aruba, mentally ill prisoners are accommodated in the vulnerable persons’ unit (Individuele Begeleidingsafdeling, IBA). In contrast to the FOBA or the EZVs, the CPT reported the critical state of the IBA’s nine cells, stating that they were “dilapidated, dirty and had very little access to natural light”, adding that the prisoners were not offered any activities.

Access to mental healthcare  ¶

A nurse examines new prisoners within 24 hours of their arrival. In particular, they evaluate suicide risk and look for addictions or a history of psychiatric issues. The prisoner is then referred to the Psycho-Medical Team (Psycho-Medisch Overleg, PMO) in charge of outpatient mental health care if necessary. In Aruba prison, there is no mental health screening for newly admitted prisoners. Requests for a consultation with a doctor or other specialist are made in writing. Each morning, the nurses create a list of prisoners who will receive a consultation with the doctor.  
In Bonaire’s JICN and Curaçao’s SDKK a request for a consultation is made by filling out a form which is then handed, without an envelope, to prison staff. On the form, prisoners have to indicate the reason for requesting medical care. The CPT reported that in Aruba, however, prison officers sort through the requests and make a judgement on their importance by themselves. The requests are often sent to the medical team after several weeks of delay.

Provision of mental health treatment ¶

An individual treatment plan must be established within ten days of arrival for a prisoner referred to the PMO. Thereafter, a consultation with a psychiatrist, a doctor, a psychologist, and a nurse takes place every two weeks. Prisoners under psychotropic medication or who are held in an EZV automatically have an individual treatment plan drawn up.

TBS patients are offered therapies selected according to their mental disorder rather than the offence they committed. Overmedication is commonplace, with medical staff in Curaçao prison favouring this treatment method particularly. However, prisoners suffering from a personality disorder do not have access to medication. Rather, an individual treatment plan is established with the patient’s involvement in the FOBA care unit.

Drug-dependent patients, whether on remand or convicted, have access to substitution therapies. 

Medical staff¶

It is mandatory to have nurses trained in psychiatry, and a permanent psychiatrist in the prisons. The Psycho-Medical Team (PMO), consisting of a psychologist and a psychiatrist, provides mental health care. The CPT reported that prisons in the Netherlands had between four and nine full-time nursing staff. They are present during the day throughout the week, but can only be reached by telephone at night or on weekends.

Bonaire prison has three full-time nurses, with an external psychologist and general practitioner visiting once a week, and an external psychiatrist attending once a month. A psychiatrist visits Curaçao prison once a week, whereas in Point Blanche Prison in Sint Maarten, a psychiatrist visits every two weeks.

Medical confidentiality ¶

The CPT reported that medical confidentiality was rarely respected in Aruba’s prison. Prison staff were frequently present during consultations in the medical unit, even during physical examinations, and medical records were left lying around in full view of other prisoners and prison staff in that unit.
In the Netherlands, the CPT observed that prisoners’ medication was prepared by external pharmacies. It was then distributed by prison staff in front of other staff members and prisoners. It also reported a lack of attention by prison staff when distributing that medication, with certain prisoners receiving the wrong medication. The CPT highlighted the risk of compromising medical confidentiality, and the impossibility of creating a relationship of trust between doctor and patient under such conditions.

Emergency measures ¶

Involuntary treatment may be used only as a last resort when a patient poses a danger to themself or others. Following a request for such treatment from a committee consisting of at least one head of department, a psychiatrist, a doctor, and a psychologist, the prison director makes a written decision on the matter. The decision remains in effect for two weeks, and can be renewed. The prison director must inform the Supervisory Committee of the prison and the Healthcare Inspectorate (Inspectie voor de Gezondheidszorg, IGZ).

In Bonaire, the CPT reported that a prisoner who refused to consent to his treatment for several days consequently received his medication through injection by force.

Prison officer training ¶

The prison officers in the EZVs receive training specific to caring for the prisoners held therein, with the CPT observing that they “worked in cooperation with psychologists and social workers.” These units also have higher staff-to-prisoner ratios than the rest of the prison.

Continuity of treatment¶

The probation service is in charge of organising care after custody for prisoners who are granted conditional release. Prisoners granted this kind of release can participate in the penitentiair programma (penitentiary programme), as long as their prison sentence was at least six months. A prisoner’s involvement in the programme requires their participation in a number of activities and can even imply a duty of care.

Involuntary admission ¶

A criminal judge can decide to have an offender committed to a psychiatric hospital without their consent through a court order. The offender can be subject to this measure if they present a severe mental disorder and pose a potential danger to themselves and others. It does not necessarily mean that they will be absolved from their criminal responsibility, and a prison sentence can be handed down in tandem with the treatment order. These offenders are subject to the Compulsory Mental Healthcare Act.

Transfers from prison  ¶

Prison medical services can request a prisoner’s transfer to a general psychiatric hospital. The request must be approved by the prison’s administration.
Transfers are rare due to the lack of places in general psychiatric hospitals and their reluctance to admit prisoners.

Legal framework  ¶

The placement, in the case of a compulsory medical care, can not exceed six months. Renewal is decided by a magistrate, and the placement itself can be re-examined, should the justification for the commitment expire.

Daily life¶

Forensic Psychiatric Departments (Forensisch Psychiatrische Afdelingen, FPA) have to accommodate TBS patients and prisoners in need of mental health care. These units are usually separated from the rest of the hospital. Their patients, upon arrival, receive a substantial prescription of medication. They are then redirected to general clinical care in the hospital or to “assisted living”.

The psychiatric department of Aruba’s hospital is not equipped to receive patients considered violent or dangerous. The CPT reported that consultations were brief, and that patients’ hands and legs were cuffed throughout.

Penitentiary Psychiatric Centres (PPC)¶

There are four PPC in the Netherlands. They have 670 places and are administered by the Ministry of Justice as part of the prison system. They are usually located inside prison compounds, where they collectively accommodate both those sentenced to prison and TBS patients. TBS patients not facing a prison sentence can be taken there when other dedicated facilities do not have places. Prisoners with severe mental health disorders ─incompatible with an ordinary prison regime─ can be transferred to a PPC.
A prisoner suffering from a mental disorder is usually transferred to a PPC when they are in a state of mental crisis or when they present a danger to themselves or others around them. The prison’s PMO makes the request to the Netherlands Institute of Forensic Psychiatry and Psychology (Nederlands Instituut voor Forensische Psychiatrie en Psychologie, NIFP) and if it is accepted, the prison administration carries out the transfer. It can take place without the consent of the prisoner. An indicted individual can be transferred from a police station to a PPC. The investigation judge can also decide on such a placement from the beginning of the detention. In that case, a psychiatric opinion is necessary.

Transfer. The psychologist in charge of PPC admissions is not present on weekends, meaning no transfer can be completed at that time. Patients who pose a serious suicide risk can be temporarily placed in an isolation cell.

Placement duration. The CPT reported that a stay in a PPC usually lasts between four and six months. A prisoner’s stay in a PPC cannot exceed the length of their sentence.

Measure review. The prisoner is transferred back to prison when their psychological state is judged stable. Transfer to a PPC can be subject to appeal before the Council for the Administration of Criminal Justice and Protection of Juveniles (Raad voor Strafrechtstoepassing en Jeugdbescherming, RSJ).

Daily life¶

Patients transferred to a PPC are held in individual cells to which they do not have the key. The CPT reported that patients spend up to 17 hours a day shut in their cells with no contact with other patients or staff. However, they can work and participate in sports, and have access to the library and common rooms during their free time.

The CPT pointed out that the use of disciplinary confinement is rare, and the staff always take into account the state of the patient’s mental health. In Zwolle’s and Scheveningen’s PPCs, the patient’s isolation can take place in their room. This isolation cannot last longer than two weeks.
Patients are transferred into isolation under the supervision of the Special Intervention Team (Intern Bijstand Team, IBT), even when they consent to the transfer. The CPT highlighted that patients placed in isolation were completely and systematically strip-searched, and were obliged to wear a rip-proof gown. Several such patients submitted complaints regarding the IBT’s use of force when they were not putting up any resistance. The CPT reported a case where one patient placed in isolation was handcuffed behind the back and laid prone on the floor. It was alleged that IBT members delivered kicks and baton blows to their legs.

Treatment plans¶

Individual treatment plans are regularly established and reviewed by the patient-care team. In the Scheveningen PPC, the CPT reported that treatment plans concentrated principally on prescribing psychotropic drugs.

Patients in the Scheveningen PPC can have an individual session with a psychologist once a week and consult a psychiatrist once a month. The CPT notes that not all patients have access to these services at this frequency. Some patients even have access to music therapy or individual psychotherapy. The CPT reported that the Zwolle PPC offer numerous non-pharmacological treatments. It nonetheless considered the prescription of medication excessive in certain cases. For example, two patients were prescribed four different psychoactive medications at once.

Treatment for TBS patients is tailored to the mental disorder from which they are suffering.

Training¶

Healthcare staff training. At Scheveningen, the healthcare staff consisted of 11 psychologists, two social psychiatric nurses, and 18 psychiatric nurses. The staff are trained in handling verbal aggression and non-compliant behaviour from patients. They also complete training on medications and their side-effects.

Prison officer training. As of 2016, the Scheveningen PPC’s staff consisted of 94 prison officers. They were trained in psychiatric care for two years. The Zwolle PPC provided multiple training courses each year. Numerous subjects were covered, including suicidal tendencies, autism, and even psychopharmacology. The CPT reported that the IBTs receive special training for handling mentally disordered patients.

Continuity of treatment  ¶

Every facility must prepare a continuity-of-care plan at least six weeks before the end of a TBS.

If a patient refuses to consent to their treatment, they can be transferred to prison. However, their medical information is not always communicated to the prison healthcare staff, which hampers the continuity of care. Short prison sentences also prevent good continuity of care.

Facilities dedicated to accommodating TBS patients¶

The judge decides where TBS patients are placed: either in an FPC or an FPK.

FPCs. Seven Forensic Psychiatric Centres (Forensisch Psychiatrisch Centrum, FPCs) accommodate TBS patients with severe mental disorders (such as schizophrenia) who require a “high level of security”. These facilities have seven long-stay units and come under the jurisdiction of the Ministry of Justice.
The consent of the patient is not required for the TBS order. The majority of individuals held in FPCs suffer from both an addiction and a mental disorder.
Prisoners who were granted conditional release can be placed in an FPC.
The long-stay units are aimed at patients who have stayed in several psychiatric facilities and who will be staying in an FPC for at least six years. This kind of placement occurs when the facility decides that the patient’s state cannot improve and that they pose a serious danger to themselves and others. Every three years, the National Independent Advisory Committee for Long-stay Placement Forensic Care (Landelijke Adviescommissie Plaatsing Longstay Forensische Zorg, LAP) assesses, on the basis of independent expertise, whether the patient should remain in an FPC, or resume their previous treatment. Sometimes, the FPCs do accommodate non-TBS patients as well.

FPKs. Forensic Psychiatric Clinics (Forensisch Psychiatrische Klinieken, FPKs) accommodate TBS patients who do not present a significant danger to themselves and others. The patient must consent to the placement. A prisoner can also be placed in an FPK when granted conditional release. There are five FPKs: each is run by a mental health facility, and they fall under the jurisdiction of the Ministry of Health. 
FPKs receive patients with both conditional and unconditional TBS.

• Conditional TBS: the patient is placed in a facility with their consent. The decision is made at the time of judgement or after the prison sentence is carried out.
• Unconditional TBS: the patient is judged to be at least partly dangerous.

Patients with substance addictions can be sent to an FPC or FPK if they suffer from a mental disorder.

Transfer. The transfer period to an FPC or FPK is usually quite long due to the lack of space. TBS patients can be sent to a prison for a maximum period of one year while awaiting their transfer. They are generally sent to an EZV.

Placement duration. On average, a TBS lasts eight years. In theory, the total length of the treatment cannot exceed four years for minor offences, and a conditional TBS cannot exceed nine years. However, around 10% of TBS patients sent to long-stay units in FPCs stay there for more than 15 years. The treatment can last until the patient’s death.

Measure review. A TBS can be renewed every two years, indefinitely. The criminal court makes a decision regarding renewal at the request of the prosecutor. It must be justified by the presence of a threat to “public safety”.
Indefinite renewal is possible for offenders who committed crimes deemed exceptionally serious. An independent expert psychiatric review must also take place every four years. The risk of re-offending must, in reality, be very small for the patient to be released.
An unconditional TBS must be re-examined at every stage of the treatment process, with patients sent to a long-stay unit in an FPC being re-examined every three years. The aim of the assessment is to evaluate whether it would be suitable to transfer the patient back to a regular treatment ward.
The patient can appeal against the TBS order. The procedure is similar to that of an appeal against a prison sentence. Appeals against a decision to send a prisoner to an FPC long-stay unit are lodged with the RSJ.

Daily life¶

Those placed in an FPC or FPK are treated as patients and their living conditions are similar to those admitted in general psychiatric hospitals. Patients can have personal belongings, spend more than four hours a day in the common areas, and do not have to work. The rooms are individual; the patients can furnish them and keep their keys. Neither the patients nor the staff wear a specific uniform.

Every patient in these facilities is not subject to the same level of security. A patient can, in fact, be granted a greater degree of freedom as their treatment progresses. They are placed in a closed unit before gaining the right to move around and being granted temporary leave permissions. FPCs have an intensive care unit for patients who are considered an escape risk.

An integral part of the treatment is contact with family and the outside world. Visits are frequent. Certain facilities have apartments where patients and their families can stay for several days. 

The rules and procedures for maintaining order are roughly the same as those observed in prisons. Placement in solitary confinement is limited to four weeks, and disciplinary measures include setting group activities as off-limits or suspending visits for a maximum of two weeks.

Treatment plans¶

A treatment plan must be established with the patient’s active involvement within three months of their admission in a TBS hospital. A consultation with several health professionals, a psychiatrist, a doctor, a psychologist, and a nurse, is scheduled every two weeks. Others can be organised according to the patient’s needs.
Individual and group therapies are organised, as well as pharmacotherapy workshops and creative therapy. Offenders who have committed aggressive crimes like assault can follow specific programmes aimed at controlling their impulsive behaviour. A special unit for sex offenders is provided in the FPK at Assen. Patients are frequently granted temporary leave in order to better prepare them for reintegration into society.

If patients do not consent to treatment, they are transferred to an FPC long-stay unit. They do not have access to group therapies and the care on offer is reduced.

A patient in a state of mental crisis can receive treatment without their consent. This treatment is usually short due to the strict conditions governing it.

Training¶

Surveillance officer training. FPCs do not have prison guards.

Healthcare staff training. The staff receive security training. The psychologists and psychiatrists are specialised in caring for prisoners. Certain nurses are also trained in social work or sociotherapy. Additional training modules are offered every year, such as aggressive behaviour management.

Continuity of treatment¶

Temporary leaves, considered a fundamental part of the treatment, facilitate a progressive reintegration into society; these can last from a few hours to several days, according to how the treatment progresses. All temporary leaves are supervised.

The court decides on the termination of the TBS. The patient is usually granted conditional release and becomes the responsibility of the probation service. FPCs and FPKs cooperate with the latter in carrying out the transition.
The conditional release can be renewed indefinitely if the person poses a danger to themselves or others. After the final release, the law no longer mandates the provision of continuous care. Outpatient services sometimes continue to follow up on certain patients.